Journal of Clinical Urology

We reviewed the empirical use of antibiotics in patients with secondary haemorrhage following transurethral resection of bladder tumour.

A retrospective review of 2830 patients undergoing TURBT between January 2006 and April 2009 was performed from two large independent urology centres in the UK. Patients with secondary haemorrhage were identified and their urine culture results and risk factors for bleeding were studied.

Secondary haemorrhage causing hospital admission was seen in 2% (51 cases). However, only 14% of these cases had significant bacteriuria on urine culture. In patients with secondary haemorrhage we show potential risk factors for bacteriuria: resection weight greater than 2g (71% versus 28%), muscle invasive bladder cancer (43% versus 20%) and macroscopic residual disease (43% versus 12%); although they did not reach statistical significance. Interestingly there was no significant difference in the clinical parameters supportive of infection between patients with bacteriuria and sterile urine — in particular only 1/51 had a temperature of greater than 37.5°C. Nevertheless, 73% (37/51) of patients were treated with antibiotics.

Typically, patients with secondary haemorrhage following TURBT do not have evidence of demonstrable infection and only a few had evidence of bacteriuria. Routine prescription of antibiotics in secondary haemorrhage following TURBT is therefore not justified.

Unnecessary laboratory utilization due to inappropriate test-ordering behaviour among hospital clinicians and community general practitioners is an ongoing problem in many hospitals and primary care trusts throughout the UK and abroad. In January 2007, our hospital removed the ‘tick box’ for PSA from its laboratory tests request form, in a managed way, with the intention of reducing unnecessary requests for this test. Here we address the impact this action had on the number of PSA tests being requested and its downstream effects on prostate cancer diagnosis.

Using our laboratory database we compared the number of hospital and local GP requests for PSA, before and after modification of our laboratory form (requests from 2004 to 2006 were compared to 2007). We then correlated this data with the number of fast-track target referrals (2 week wait) from primary care for suspected prostate cancer, the results of prostate biopsies, and the number of prostate cancers being diagnosed, over the same time period.

Mann—Whitney non-parametric testing demonstrated a 17% reduction in the median number of PSA requests since the change was introduced (p = 0.001). Subset analysis revealed an 18% reduction in GP requests (p = 0.002). However no change was found in the number of prostate cancer diagnoses being made (p = 0.86) and the number of target referrals for suspected prostate cancer (p = 0.59) in the months of April, May, June, July, August and September of 2004–2006 as compared to the same months in 2007. The rate of patients undergoing biopsy increased in the post intervention period from 15.5 to 18.5 patients per month. The rate of negative biopsies remained stable, changing from 7.2 to 7.3 per month, and the rate of positive biopsies increased from 8.3 to 11.2 per month. This change reduced the false negative rate (suspected cancer, negative biopsy) from 46% to 40% in the period following the intervention. The rate of target referrals leading on to cancer showed a small increase after the intervention from 2.9 to 3.3 per month.

Our study shows that with this simple modification to the design of our laboratory request form, whereby the doctor must make an active written decision to order a PSA test, there was a significant reduction in the number of PSA requests, both in the hospital and in the community, without patient safety being compromised as measured by maintaining the number of fast-track target referrals for suspected prostate cancer and the number of prostate cancers diagnosed.

To determine whether social deprivation influenced the rate of PSA testing per head of male population within the catchment area of our institution.

We retrospectively collated all PSA tests performed by general practitioners within an 18-month period in the catchment area of our institution (n = 10,695). PSA testing frequency within each lower super output area (LSOA) within the catchment area of our hospital was determined. The social deprivation of each LSOA was assessed using the Index of Multiple Deprivation 2007 index (IMD). Using these data, the percentage of men undergoing PSA tests in each LSOA was calculated as was the percentage of positive tests amongst those tested. Logistic regression analysis was performed with age and IMD 2007 scores as covariates.

Increasing IMD 2007 score was independently associated with a decreased likelihood of PSA testing (odds ratio 0.976 (95% confidence interval 0.959–0.994) p = 0.008). There was no association between IMD 2007 score and the rate of positive tests (odds ratio 0.997 (0.984–1.009) p = 0.60).

Increasing levels of social deprivation demonstrate a small but significant association with a lower incidence of PSA testing in the catchment area of our institution. © 2011 British Association of Urological Surgeons. Published by Elsevier Ltd. All rights reserved.

To determine whether patients with diabetes undergoing day surgery in urology units in the North West of England were managed in accordance with published national guidelines.

Data on day cases were collected from 14 NHS Trusts in the region. Proformas including details of pre-operative assessment, peri-operative care and discharge were completed by independent data collectors in individual units. These were audited against the British Association of Day Surgery guidelines for management of patients with diabetes as day cases.

7 patients with type 1 diabetes and 77 with type 2 underwent day case procedures. At pre-operative assessment, 71% patients had a documented glycosylated haemoglobin (HbA1C), 32% had stable serum glucose and 62% had no history of hypoglycaemic attacks. Peri-operatively, 69% had a blood glucose <10mmol/l, 17% had a blood glucose >10mmol/l and in 14% it was not documented. A Glucose-potassium-insulin infusion was commenced in 91% of patients on insulin. On discharge, less than 25% patients were given written advice.

Whilst compliance with published guidelines is generally good throughout the region, there is significant room for improvement particularly with respect to documentation and discharge planning. Implementation of dedicated protocols can bring about consistent improvement in practice.